Guide to Community Preventive Services
The Effectiveness of Limiting Alcohol Outlet Density
As a Means of Reducing Excessive Alcohol
Consumption and Alcohol-Related Harms
Carla Alexia Campbell, MHSc, Robert A. Hahn, PhD, MPH, Randy Elder, PhD, Robert Brewer, MD, MSPH,
Sajal Chattopadhyay, PhD, Jonathan Fielding, MD, MPH, MBA, Timothy S. Naimi, MD, MPH,
Traci Toomey, PhD, Briana Lawrence, MPH, Jennifer Cook Middleton, PhD, the Task Force on Community
Preventive Services
Abstract:
The density of alcohol outlets in communities may be regulated to reduce excessive alcohol
consumption and related harms. Studies directly assessing the control of outlet density as
a means of controlling excessive alcohol consumption and related harms do not exist, but
assessments of related phenomena are indicative. To assess the effects of outlet density on
alcohol-related harms, primary evidence was used from interrupted time–series studies of
outlet density; studies of the privatization of alcohol sales, alcohol bans, and changes in
license arrangements—all of which affected outlet density. Most of the studies included in
this review found that greater outlet density is associated with increased alcohol consumption and related harms, including medical harms, injury, crime, and violence. Primary
evidence was supported by secondary evidence from correlational studies. The regulation
of alcohol outlet density may be a useful public health tool for the reduction of excessive
alcohol consumption and related harms.
(Am J Prev Med 2009;37(6):556 –569) Published by Elsevier Inc. on behalf of American Journal of
Preventive Medicine
Introduction
E
xcessive alcohol consumption, including both
binge drinking and heavy average daily alcohol
consumption, is responsible for approximately
79,000 deaths per year in the U.S., making it the
third-leading cause of preventable death in the nation.1
Approximately 29% of adult drinkers (ⱖ18 years) in
the U.S. report binge drinking (five or more drinks on
one or more occasions for men and four or more
drinks for women) in the past 30 days, as do 67% of
high school students who drink.2,3 The direct and
indirect costs of excessive alcohol consumption in 1998
were $184.6 billion.4 The reduction of excessive alcohol
consumption is thus a matter of major public health
and economic interest.
From the Community Guide Branch of the National Center for
Health Marketing (Campbell, Hahn, Elder, Chattopadhyay, Lawrence, Middleton); National Center for Chronic Disease Prevention
and Health Promotion (Brewer, Naimi), CDC, Atlanta, Georgia; Los
Angeles County Department of Health Services (Fielding), Los
Angeles, California; and University of Minnesota School of Public
Health (Toomey), Minneapolis, Minnesota
Address correspondence and reprint requests to: Robert A. Hahn,
PhD, MPH, Community Guide Branch, Division of Health Communication and Marketing, Centers for Disease Control and Prevention,
4770 Buford Highway, Mailstop E-69, Atlanta GA 30333. E-mail:
rhahn@cdc.gov.
556
The density of retail alcohol outlets is often regulated
to reduce excessive alcohol consumption and related
harms. Alcoholic beverage outlet density refers to the
number of physical locations in which alcoholic beverages are available for purchase either per area or per
population. An outlet is a setting in which alcohol may
be sold legally for either on-premises or off-premises
consumption. On-premises settings may include restaurants, bars, and ballparks; off-premises settings may
include grocery and convenience stores as well as liquor
stores. In 2005, the most recent year for which data are
available, there were more than 600,000 licensed retail
alcohol outlets in the U.S., or 2.7 outlets per 1000
population aged ⱖ18 years.5 The number of outlets per
capita in states with state-owned retail outlets varied
from a low of 0.48 per 1000 residents in Mississippi to a
high of 7.25 per 1000 in Iowa.5
Alcohol outlet density is typically controlled by states.
Under state jurisdiction, outlet density may be regulated at the local level through licensing and zoning
regulations, including restrictions on the use and development of land.6 This regulation may be proactive as
part of a community development plan, or in response
to specific issues or concerns raised by community
leaders. However, local control can be limited by state
pre-emption laws, in which state governments explicitly
or implicitly curtail the ability of local authorities to
Am J Prev Med 2009;37(6)
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
0749-3797/09/$–see front matter
doi:10.1016/j.amepre.2009.09.028
regulate outlet expansion.7 Thus, both state and local
policies need to be considered when assessing factors
that affect outlet density.
The WHO has published a review that identifies
outlet density control as an effective method for reducing alcohol-related harms.8 Similarly, in 1999, the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Prevention review
concluded that there was a “medium” level of evidence
supporting the use of outlet density control as a means
of controlling alcohol-related harms.9 In addition, several organizations have advocated the use of outlet
density regulation for the reduction of alcohol consumption and alcohol-related harms. These include the
European Union (in their 2000 –2005 Alcohol Action
Plan)10 and the WHO Western Pacific Region.11 The
criteria used in the WHO report are not specified and
may be expert opinion rather than systematic assessment of the characteristics of available studies. The
SAMHSA review uses specified characteristics of included studies in drawing conclusions; however, the
studies included are not up to date. In the present
synthesis, 14 of the studies reviewed were published
after 2000. Finally, a recent review by Livingston et
al.12 presents useful conceptual hypotheses and notes
the importance of outlet “bunching”—which the
team referred to as “clustering”— density at a more
micro level.
Further, the present review assesses whether interventions limiting alcohol outlet density satisfy explicit
criteria for intervention effectiveness of the Guide to
Community Preventive Services (Community Guide), and
assesses studies available as of November 2006. In
addition, unlike any of the prior documents, the
present review considers evidence from assessments
of policies that are not explicitly considered densityrelated but that have direct effects on outlet density
(i.e., privatization, liquor by the drink, and bans). If
effective, policies limiting alcohol outlet density might
address several national health objectives related to
substance abuse prevention that are specified in Healthy
People 2010.13
Guide to Community Preventive Services
The systematic review described in this report represents the work of CDC staff and collaborators on behalf
of the independent, nonfederal Task Force on Community Preventive Services (Task Force). The Task
Force is developing the Community Guide with the
support of the USDHHS in collaboration with public
and private partners. The book The Guide to Community
Preventive Services. What Works to Promote Health? presents
the background and the methods used in developing
the Community Guide.14
December 2009
Methods
The methods of the Community Guide review process15,16 were
used to assess whether the control of alcohol outlet density is
an effective means of reducing excessive alcohol consumption and related harms. In brief, this process involves
forming a systematic review development team (the team);
developing a conceptual approach to organizing, grouping, and selecting interventions; selecting interventions to
evaluate; searching for and retrieving available research evidence on the effects of those interventions; assessing the
quality of and abstracting information from each study that
meets inclusion criteria; drawing conclusions about the body
of evidence of effectiveness; and translating the evidence on
intervention effectiveness into recommendations. Evidence is
collected on positive or negative effects of the intervention on
other health and nonhealth outcomes. When an intervention
is shown to be effective, information is also included about
the applicability of evidence (i.e., the extent to which available
effectiveness data might generalize to diverse population segments and settings), the economic impact of the intervention,
and barriers to implementation. The results of this review
process are then presented to the Task Force on Community
Preventive Services (Task Force), an independent scientific
review board from outside the federal government, which
considers the evidence on intervention effectiveness and
determines whether the evidence is sufficient to warrant a
recommendation.15
Conceptual Approach and Analytic Framework
Outlet density is hypothesized to affect excessive alcohol
consumption and related harms by changing physical access
to alcohol (i.e., either increasing or decreasing proximity to
alcohol retailers), thus changing the distance that drinkers
need to travel to obtain alcohol or to return home after
drinking. Increases in the density of on-premises outlets can
also alter social aggregation, which may adversely affect those
who are or who have been drinking excessively, leading to
aggressive or violent behavior (Figure 1). With alcoholic
beverages acquired in off-premises settings, the consumption
more often occurs at the purchaser’s home, and excessive
consumption may be associated with domestic violence and
suicidal behavior.
Decreases in off-premises or on-premises alcohol outlets, or
both, are expected to decrease access to alcoholic beverages
by increasing the distance to alcohol outlets, increasing
alcohol prices, reducing exposure to on-premises alcohol
marketing, and potentially by changing social norms around
drinking, thereby decreasing excessive alcohol consumption
and related harms. Decreases in outlet density are expected
to decrease social aggregation in and around on- and offpremises alcohol outlets which, in turn, may decrease aggressive behavior potentially exacerbated by alcohol consumption.17 Finally, decreased density increases distances traveled
to and from alcohol outlets, thus increasing the potential for
alcohol-related crashes. However, this potential harm could
be mitigated by decreased alcohol consumption and hence
decreased alcohol-impaired driving.18,19 Thus, the expected
effect of outlet density on motor-vehicle crashes may be
mixed.20
The effect that density has on consumption and harms
may be further influenced by at least seven characteristics
Am J Prev Med 2009;37(6)
557
Figure 1. Analytic framework showing the hypothesized effects of changes in outlet density on excessive alcohol consumption
and related harms
of retail alcohol outlets and the communities in which they
are located: (1) outlet size (i.e., the physical size of the
retail premises or the volume of its sales); (2) clustering
(i.e., the level of aggregation of outlets within a given
area); (3) location (i.e., the proximity of alcohol retail sites
to places of concern, such as schools or places of worship);
(4) neighboring environmental factors (e.g., demographics of the community and the degree of isolation of a
community); (5) the size of the community (which may affect
access to other retail sites); (6) the type and number of
alcohol outlets (e.g., bar, restaurant, liquor store, grocery
store) in a community may also influence whether and how
outlet density affects drinking behavior21; and (7) alcohol
outlets may be associated with illegal activities, such as drug
abuse, which may also contribute to public health harms. As
with other policies and regulations, the effects of regulations
affecting outlet density may depend on the degree to which
the policies are implemented and enforced.
There are several challenges to directly evaluating the
effectiveness of local policies in changing outlet density on
alcohol consumption and related harms. Direct studies of the
effects of policies changing density on alcohol-related public
health outcomes have not been conducted. Policy changes
may occur in small communities in which documentation and
558
data may be unavailable and where the number of retail
alcohol outlets, alcohol-related outcomes, or both may be
small; thereby it may be difficult to assess the relationship
between outlet density and excessive alcohol consumption
and related harms. Further, the effects of policy decisions on
outlet density may be gradual. Other changes in alcohol
control policies (e.g., enhanced enforcement of the minimum legal drinking age) may occur simultaneously, making it
difficult to isolate the effect of changes in outlet density on
drinking behavior.
The team used both primary and secondary scientific
evidence to help address these challenges and to comprehensively assess the impact of changes in alcohol outlet density on
excessive alcohol consumption. Primary evidence included
studies comparing alcohol-related outcomes before and after
a density-related change. In this category were (1) studies
assessing the impact of privatizing alcohol sales— commonly
associated with increases in density; (2) studies assessing the
impact of bans on alcohol sales—associated with decreases in
density; and (3) studies of other alcohol licensing policies
that directly affect outlet density (e.g., the sale of liquor by the
drink). Time–series studies (i.e., studies in which the association
between changes in outlet density and alcohol-related outcomes
is assessed over time) were also used to provide primary evidence
American Journal of Preventive Medicine, Volume 37, Number 6
www.ajpm-online.net
of intervention effectiveness, even when the cause of the observed change in outlet density was unknown. The team did not
include studies of strikes in the production or distribution of
alcoholic beverages or studies of interventions among college
populations. Secondary evidence included cross-sectional studies, which do not allow the inference of causality.
Inclusion and Exclusion Criteria
To be included in this review, studies had to meet the
following criteria: First, they had to evaluate changes in outlet
density or policy changes that clearly resulted in changes in
outlet density. Studies of policy changes (e.g., privatization or
the legalization of liquor by the drink) had to provide
evidence that there was a corresponding change in alcohol
outlet density. Second, studies had to be conducted in
high-income nations,a,22 be primary research (rather than a
review of other research), and be published in English. Third,
studies had to report outcome measures indicative of excessive alcohol consumption or related harms. Direct measures
that had the strongest association with excessive alcohol
consumption included binge drinking, heavy drinking, liver
cirrhosis mortality, alcohol-related medical admissions, and
alcohol-related motor-vehicle crashes, particularly singlevehicle nighttime crashes, which are widely used to indicate
motor-vehicle crashes due to drinking and driving.23 Less
direct measures included per capita ethanol consumption,
which is a well-recognized proxy for the prevalence of heavy
drinkers in a population8,24; unintentional injuries; suicide;
and crime, such as homicide and aggravated assault. In most
studies included in this review, consumption is measured by
sales data; the team referred to this measure as “consumption” and note the exceptional study in which self-reported
consumption is directly assessed. Fourth, studies had to be
published in a peer-reviewed journal or in a government
report. Reports not published or published by private organizations were not included.
Search for Evidence
The following databases were searched from inception up
to November 2006 to identify studies assessing the impact
of changes in alcohol outlet density and other review
topics: EconLit, PsycINFO, Sociological Abstracts, MEDLINE,
EMBASE, and EtOH (no longer available after 2003). The
search yielded 6442 articles, books, and conference abstracts,
of which 5645 were unique. After screening titles and abstracts, 251 papers and articles and 17 books were retrieved
specifically related to outlet density; five articles could not be
retrieved. After assessing quality of execution and design
suitability (see below), 88 articles or books were included in
the review. The actual number of studies that qualified for the
a
World Bank High-Income Economies (as of May 5, 2009): Andorra,
Antigua and Barbuda, Aruba, Australia, Austria, the Bahamas, Bahrain, Barbados, Belgium, Bermuda, Brunei Darussalam, Canada,
Cayman Islands, Channel Islands, Cyprus, Czech Republic, Denmark,
Equatorial Guinea, Estonia, Faeroe Islands, Finland, France, French
Polynesia, Germany, Greece, Greenland, Guam, Hong Kong (China),
Hungary, Iceland, Ireland, Isle of Man, Israel, Italy, Japan, Republic
of Korea, Kuwait, Liechtenstein, Luxembourg, Macao (China), Malta,
Monaco, Netherlands, Netherlands Antilles, New Caledonia, New
Zealand, Northern Mariana Islands, Norway, Oman, Portugal, Puerto
Rico, Qatar, San Marino, Saudi Arabia, Singapore, Slovak Republic,
Slovenia, Spain, Sweden, Switzerland, Trinidad and Tobago, United
Arab Emirates, United Kingdom, U.S., Virgin Islands (U.S.)
December 2009
review was less than this, however, because some studies were
described in more than one report or publication.
Assessing the Quality and Summarizing the Body
of Evidence on Effectiveness
Each study that met the inclusion criteria was read by two
reviewers who used standardized review criteria (available at
www.thecommunityguide.org/library/ajpm355_d.pdf) to assess the suitability of the study design and threats to validity.
Uncertainties and disagreements between the reviewers were
reconciled by the team. The classification of study design was
based on Community Guide standards, and thus may differ
from the classification reported in the original studies. Studies with greatest design suitability were those in which data on
exposed and control populations were collected prospectively. Studies with moderate design suitability were those in
which data were collected retrospectively or in which there were
multiple pre- or post measurements but no concurrent comparison population. Studies with least-suitable designs were crosssectional studies or those in which there was no comparison
population and only a single pre- and post-intervention measurement. On the basis of the number of threats to validity
(maximum: nine; e.g., poor measurement of exposure or outcome, lack of control of potential confounders, or high attrition) studies were characterized as having good (one or fewer
threats to validity); fair (two to four threats); or limited (five or
more threats) quality of execution. Studies with good or fair
quality of execution, and any level of design suitability (greatest, moderate, or least), qualified for the body of evidence
synthesized in the review.
The team summarized the results of cross-sectional studies
based on whether drinking occurred on- or off-premises.
However, some studies did not stratify their findings by outlet
type and so were presented in a combined category. For each
outcome and setting, the team summarized study findings by
comparing the relative number of positive and negative
findings. Finally, elasticities—summary effect measures showing the percentage change in an outcome per 1% change in
an exposure (e.g., outlet density)—were calculated if the
study provided sufficient information.
Other Harms and Benefits, Applicability, Barriers,
and Economics
Harmful and beneficial outcomes not directly related to
public health (e.g., vandalism or public nuisance) were noted
if they were described in the studies reviewed or if the team
regarded them as plausible. In addition, if an intervention was
found to be effective, the team assessed barriers to implementation; the applicability of the intervention to other settings,
populations, or circumstances; and the economic costs and
benefits of the intervention.
Results
Intervention Effectiveness—Primary Evidence
Time–series studies of alcohol outlet density change. The
team found ten studies20,25–33 that directly evaluated the
effect of changes in outlet density over time without
identifying the causes for density changes. Of these,
eight were “cross-sectional time–series” (i.e., panel)
Am J Prev Med 2009;37(6)
559
studies of greatest design suitability20,25–29,31,33 and
two were single-group time–series studies of moderate design suitability.30,32 Eight of the studies were
of good execution25–31,33 and two were of fair execution.20,32 Few took spatial lag (i.e., the likelihood that
neighboring geographic units are not statistically
independent) into account. Five studies assessed
associations between changes in outlet density and
population-level alcohol consumption,25,26,28,31,33
and the remainder assessed specific alcohol-related
harms.20,27,29,30,32
Consumption. All five studies that assessed the association between outlet density and population-level alcohol consumption found that they were positively associated; increased density was associated with increased
consumption, and vice versa. Three studies examined
the relationship between outlet density and the consumption of spirits in the U.S. The first study estimated
that, from 1955 to 1980, for each additional outlet
license per 1000 population, there was an increase of
0.027 gallons in per capita consumption of spirits
ethanol (p⬍0.01).28 The second study reported an
elasticity of 0.14 (p⬍0.01) for outlet density and spirits
for the period 1970 –1975.31 The third study examined
the association of outlet density and the sale of spirits
and wine in 38 states over a period of 18 years; the
effects of consumption on density were separated out
by use of two-stage least squares regression. The elasticity for spirits and wine was found to be 0.033 (NS) and
0.015 (NS), respectively.26
A study assessing trends from 1952 to 1992 in the
United Kingdom25 reported an elasticity of 2.43 (p⬍
0.05) for off-premises density and beer consumption
but no significant association for other beverages (except hard cider). Finally, a study33 examining data from
1968 to 1986 in Canada reported a significant association between reductions in off-premises density and
reductions in alcohol consumption. This study also
found an association between changes in outlet
density and cirrhosis mortality, which was mediated
by changes in alcohol consumption. When the alcohol consumption variable was added to the analytic
model, the coefficient for cirrhosis mortality was no
longer significant.
Motor-vehicle crashes and other injury outcomes. Two
studies by one author,20,30 using the same methods and
database in California, found mixed results when evaluating the association between on- and off-premises
outlet density and fatal and nonfatal motor-vehicle
crashes in small California cities (i.e., with total populations ⬍50,000) during two different time periods and
among different populations. The first study assessed
the association between outlet density and crashes from
1981 through 1989 across all age groups. The author
found a negative association between off-premises outlet density and both fatal and nonfatal crashes, and a
560
positive association between on-premises outlets and
both fatal and nonfatal crashes.20 The second study
assessed the association between outlet density and
fatal and nonfatal crashes from 1981 through 1998
among people aged ⱖ60 years. This study reported a
negative association for nonfatal crashes (elasticity:
⫺0.69, p⬍0.05) and a positive association for fatal
crashes (elasticity: 1.18, p⬍0.05).
Three studies27,29,32 assessed the relationship between outlet density and suicide or interpersonal violence. A study of young people aged 10 –24 years in the
U.S. from 1976 through 1999 found positive associations between outlet density (on- and off-premises
outlets combined) and suicides for most gender and
age strata assessed, but only the findings for boys/men
aged 15–19 years were significant (elasticities ranged
from ⫺0.03 to 0.10 for girls/women and from 0.05 to
0.12 for boys/men).29
The effect of changes in the density of on-premises
outlets and violent crime was investigated in Norway
from 1960 through 1995.32 The researcher used autoregressive integrated moving average (ARIMA) modeling and found that each alcohol outlet was associated
with 0.9 violent crimes investigated (by the police) per
year. A supplementary analysis found that this association persisted even after controlling for amount of
alcohol consumption, suggesting that the effect of
increased density was independent of the effect
of increased alcohol consumption (p⬍0.03). This suggests
that the social aggregation of drinkers in and around
alcohol outlets directly affects assaults, as indicated in
Figure 1 (under “social problems”).
Finally, a study of 581 California neighborhoods
identified by ZIP code from 1996 through 200227
indicated that an increase in on- and off-premises outlet
density was associated with an increase in hospitalizations for assault, but that this association varied for
on-premises and off-premises locations, and among
various types of on-premises locations (e.g., bar or
restaurant) as well. The researchers used random-effects
regression models, taking spatial lag into account, thus
allowing for the lack of independence of neighborhoods
in the association of outlets and alcohol-related harms.
Within a given ZIP code, the elasticity for off-premises
outlets and alcohol-related assaults on residents was
0.167 (p⬍0.001); for restaurants, it was ⫺0.074
(p⬍0.01); and for bars, 0.064 (p⬍0.001). The elasticity
for bars and assaults involving residents of neighboring
ZIP codes was also significant (0.142, p⬍0.001); however, the elasticities for off-premises alcohol outlets and
for restaurants relative to assaults involving residents of
neighboring ZIP codes were not significant. Based on
these results, the authors estimated that, on average,
eliminating one bar per ZIP code in California would
reduce the number of assaults requiring overnight
hospitalization by 290 per year in the state.
American Journal of Preventive Medicine, Volume 37, Number 6
www.ajpm-online.net
Summary
Seven of nine time–series studies found positive associations between changes in outlet density and alcohol
consumption and related harms, particularly interpersonal violence. However, two studies assessing the relationship between alcohol outlet density and motorvehicle crashes in small California cities during two
different time periods20,30 had inconsistent findings for
which no clear explanation was apparent. The studies
reviewed also suggested that the association between
outlet density and interpersonal violence may at least
partially be due to social aggregation in and around
alcohol outlets, and that the density of outlets in a given
locale can also influence the probability of assaults
involving residents of neighboring communities.
Privatization Studies
Alcohol privatization involves the elimination of government monopolies for off-premises alcohol sales to
allow sales by privately owned enterprises. In the U.S.
and Canada, privatization occurs at the state or provincial level; in many European nations, privatization may
occur at a national level, currently guided by policies of
the European Union. In the U.S., one alcoholic beverage may be privatized at a time; for example, wine
might be privatized (i.e., subsequently for sale in commercial settings) while spirits may not be privatized, or
may be privatized at a different time. Typically, privatization results not only in a substantial increase in the
number of outlets where alcohol can be purchased but
also in changes in alcohol price, days and hours of sale,
and marketing.21,34 This combination of events limits
the ability to attribute subsequent changes in alcohol
consumption and related harms to changes in outlet
density alone. Nonetheless, because of the impact
privatization generally has on outlet density, the team
concluded that privatization studies were relevant for
assessing the impact of changes in outlet density on
excessive alcohol consumption and related harms.
The effects of privatization on the privatized beverages are assessed first, followed by an assessment of the
effects of privatization on beverages other than those
for which sales were privatized. If privatization affects
consumption and related harms by means of increased
outlet density, the consumption (and related harms) of
the privatized beverage should increase, while consumption of other beverages might decline if usual
drinkers of these other beverages now switch to the
newly available privatized beverage. Comparing the
association between alcohol consumption and alcoholrelated harms associated with privatized and nonprivatized alcoholic beverages, respectively, provides a basis
for assessing the impact of privatization on alcohol
consumption and related harms while controlling for
other factors that might be occurring simultaneously.
December 2009
Following an analysis of the effects of privatization,
this section then reviews the effects of remonopolization, that is, reversing privatization by reinstatement of
government monopoly control over the retail sales of
alcohol beverages. This policy change would be expected to have the opposite effects of privatization and
result in lower alcohol outlet density.
Eleven events of privatization and one of remonopolization, analyzed in 17 studies and reported in 12 papers,35– 45 met the review inclusion criteria. The units of
analysis were eight U.S. states (AL, ID, IA, ME, MT, NH,
WA, WV); two Canadian provinces (Quebec and Alberta);
and (in the sole study of remonopolization) Sweden.
Several studies assessed overlapping privatization events.
For example, two research teams assessed the privatization of wine and then spirits in Iowa,34,38,39,45 and two
researchers assessed early phases of the privatization of
wine in Quebec, while one of these researchers also
assessed the later phases, with each phase counted as a
separate privatization event.36,46 In addition, several
papers assessed the effects of privatization in more than
one state and provided separate effect estimates for the
privatization in each state; for purposes of this review,
each state-level assessment was treated as a separate
study. Finally, a single state or province could privatize
different beverages at different times, resulting in
separate privatization events. Altogether, the events
assessed in these studies occurred between 1978 and
1993. In all areas assessed, the number of outlets
increased dramatically following privatization. The
studies used ARIMA time–series study design; all
except two studies36,46 reported results for comparison populations.
All studies used alcohol sales data as a measure of
population-level alcohol consumption. One study also
assessed fatal motor-vehicle crashes (MVCs),42 another
study34 also evaluated single-vehicle nighttime crashes
and liver cirrhosis. The single study of remonopolization40 assessed hospitalizations for alcoholism, alcohol
intoxication, and alcohol psychosis combined, alcohol
intoxication alone, assaults, suicides, falls, and MVCs.40
Fourteen studies (in seven papers)35,38,39,42– 44,46 were
of greatest design suitability; three studies (in two
papers)37,40 were of moderate design suitability. All
studies were of fair execution.
Effects of Privatization on Privatized Beverages
Seventeen studies35– 44 assessed the effects of privatization on the sale of at least one of four beverage types
(wine, spirits, full-strength beer, and medium-strength
beer) in ten settings. The median relative increase in
alcohol sales subsequent to privatization was 42.0%,
with an interquartile interval of 0.7% to 136.7%. That
is, among the studies reviewed, compared with consumption prior to privatization, the median effect was
Am J Prev Med 2009;37(6)
561
an increase of 42.0% in consumption of the privatized
alcoholic beverage. Studies of three events of privatization, two in Iowa and one in Alberta, yielded inconsistent findings, which merit further description.
In Iowa, wine was privatized in 1985, and spirits in
1987. Wagenaar and Holder35,43 reported that wine
consumption increased 93.0% (95% CI⫽69.3, 120.2)
from baseline to 44 months after privatization of retail
wine sales. Following the subsequent privatization of
retail spirits sales in Iowa 2 years later, these researchers35,43 reported a 9.5% (95% CI⫽3.5, 15.9) increase in
spirits consumption; they also found no evidence that
privatization affected cross-border alcohol purchasing.35,43 In contrast, Mulford and Fitzgerald39 found
that wine privatization in Iowa was associated with a
nonsignificant increase of only 0.5% (95% CI⫽ ⫺13.2,
16.4) in wine sales, and that spirits privatization was
associated with a nonsignificant increase of 0.7% (95%
CI⫽ ⫺4.3, 6.0) in spirits sales. Differences between the
findings of these research groups may be due to
differences in time periods assessed, modeling variables
and procedures, beverage types included in the assessment (e.g., Mulford and Fitzgerald exclude wine coolers that were not affected by the policy change and
Wagenaar and Holder do not), use of a control population, and outcome measurement. Fitzgerald and Mulford34 also report small unadjusted rate decreases in
single-vehicle nighttime crashes (⫺1.6%) and alcoholic
cirrhosis mortality (⫺5.5%) associated with the privatization of wine and spirits in Iowa.
A study in Alberta, Canada, estimated that gradual
privatization over a period of 20 years resulted in an
increase in spirits consumption of 12.7% (95% CI⫽2.2,
24.4) and no change in either wine or beer consumption.42 Although the process of privatization occurred
over an extended period, the major events of privatization occurred essentially at the same time (in 1992);
thus, considered in aggregate, privatizing spirits in
Alberta increased total alcohol sales by 5.1% (95% CI⫽
⫺2.8, 13.7) over this 20-year period. Despite the increased alcohol sales, the authors reported that there
was an estimated 11.3% (95% CI⫽ ⫺33.8, 19.0) decrease in traffic fatalities. However, neither the increase
in total alcohol sales nor the decrease in traffic fatalities
was significant.
Effects of Privatization on Beverages Not
Subject to Privatization
Five publications37,38,43,44,47 assessed the effects of privatization in eight settings on the concomitant sales of
alcoholic beverages that were not privatized during the
same period. Overall, these studies reported that there
was a minimal decline: a median of 2.1% (interquartile
interveral [IQI]: ⫺4.8% to 2.7%) in the sales on
nonprivatized beverages.
562
Effects of Remonopolization on Alcohol-Related
Outcomes
A single before-and-after study40 evaluated the effects of
remonopolization of sales of medium-strength beer in
Sweden. This study compared the association between
the number of retail alcohol outlets and the occurrence
of six different alcohol-related outcomes during a
51-month period following the remonopolization of
medium-strength beer, with that for a similar period
prior to remonopolization. Among young people aged
10 –19 years, alcoholism, alcohol intoxication, and alcohol psychosis (which were considered in combination) decreased by 20% (p⬍0.05) following remonopolization. These outcomes also decreased by ⬎5%
among people aged ⱖ40 years, although the change
was not significant (p⬎0.05). Hospitalizations for acute
alcohol intoxication also decreased between 3.5% and
14.7% (p⬎0.05); suicides decreased by 1.7% to 11.8%
(p⬎0.05); and falls decreased by 3.6% to 4.9% (p⬎
0.05) following remonopolization, although none of
these changes were significant either. Motor-vehicle
crashes (MVCs) significantly decreased by 14% (p⬍
0.05) in all age categories except one (those aged
20 –39 years). Other nonsignificant changes include
assaults, which decreased by 1.4% among those aged
20 –39 years, but increased by 6.9% to 14.8% (p⬎0.05)
in the other age groups: 10 –19, 40 –59, ⱖ60 years. The
authors did not provide any explanation for this seemingly inconsistent finding.
Summary
These studies indicate that privatization increases the
sales of privatized beverages but has little effect on the
sales of nonprivatized alcoholic beverages. The one
study that evaluated the reintroduction of government
monopoly control of sale of an alcoholic beverage
(medium-strength beer) found that remonopolization
led to a significant decrease in motor-vehicle crashes
for most age groups and a significant decrease among
youth for several, but not all, alcohol-related harms.
Studies of Alcohol Bans
The team found seven studies18,41,48 –52 that examined
the effects of bans on local on- or off-premises alcohol
sales or consumption (i.e., “dry” towns, counties, or
reservations). Five studies examined the effects of
bans in American Indian and Native settings in
Alaska,49,50,53 northern Canada,52 and the southwestern U.S.51 Two studies assessed the effects of bans in
nontribal areas of the U.S. and Canada.18,41 Two
studies were of greatest design suitability18,41; two of
moderate design suitability50,51; and three of least
suitable design.49,52,53 All were of fair execution. The
studies examined events that occurred from 1970
American Journal of Preventive Medicine, Volume 37, Number 6
www.ajpm-online.net
through 1996. Two additional studies modeled the association of multiple policies, including local policies of dry
counties, with spirits consumption28 and with juvenile
suicide.29 Both of these studies were of greatest design
suitability and good execution, and the team considered
them comparable to studies of bans and as primary
evidence.
An additional cross-sectional study of bans54 was not
used as primary evidence of effectiveness, but provided
insights into the effect that alcohol availability in areas
surrounding dry communities (e.g., outside Indian reservations) has on the occurrence of alcohol-related harms
among residents of the dry communities.
ban alcohol in 1978. Although comparative data are
not available from this study (and the study thus does
not meet review inclusion criteria), it is notable that
during the 3 years following the implementation of
this prohibition there were only five arrests for the
illegal possession of alcohol and, of these, four were
associated with a single incident. The reported reduction in alcohol consumption in general and among youth
in particular was linked with several societal benefits,
including improved mental and physical health among
community members, and a reduction in conflicts within
the community. The ban on alcohol sales was associated
with a reduction in the use of other substances of abuse
(e.g., inhalants) by youth.
Effects of Alcohol Bans in Isolated Communities
All of the studies that evaluated the effect of bans in
isolated northern communities found substantial reductions in alcohol-related harms with the exception of
suicide.18,41,49,51–59 In the communities that instituted
bans, rates of harm indicated by alcohol-related medical
visits were reduced by 9.0% for injury deaths to 82% for
alcohol-related medical visits (CIs not calculable). One of
these studies50 found that the effects were reversed when
the ban was lifted, and found similar benefits when the
ban was then reimposed (Figure 2).50 Two of these studies
suggest that bans on alcohol sales in isolated communities
led residents to decrease their use of other intoxicants. In
Barrow, Alaska, medical visits for use of isopropyl alcohol
declined during ban periods.50
An additional study qualitatively evaluated a Canadian Inuit community52 that overwhelmingly voted to
Effects of Alcohol Bans in Less-Isolated Communities
Monthly average number of visits per period
Studies assessing the impact of bans (particularly bans on
on-premises sales) in less-isolated communities have produced mixed results. Some studies have found that bans
are associated with increases in alcohol-related harms,
including motor-vehicle crashes18,46 and alcohol-related
arrests.51 However, two studies28,29 found that states that
had a larger proportion of their population living in dry
counties had less alcohol consumption and related
harms than states that had a smaller proportion of their
population living in dry counties. One study28 found
that living in dry counties was associated with lower
rates of spirits consumption (p⬍0.01). The other
study found small, nonsignificant associations with
male suicide (elasticities of ⫺0.002 to ⫺0.066) and
female suicide (elasticities of ⫺0.021 to ⫺0.038).29
A cross-sectional study of
injury deaths in New Mexico54 highlights the poten100
tial harms associated with al90
cohol sales bans in areas (in
Total
this case reservations, 80% of
80
Withdrawal
which are dry) that are adjaMedical/GI
70
cent to other areas where alTrauma
cohol is readily available.
60
Acute intoxication/
This study found that in
detoxification
these settings, although the
50
Suicide attempt
relative risk (RR) of total in40
jury deaths was greater for
Family violence
American Indians than for
Exposure
30
whites (RR⫽3.1; 95% CI⫽2.6,
Isopropyl
20
3.6),
the relative risk was greatPregnancy
est for deaths involving pedes10
trians struck by vehicles
(RR⫽7.5; 95% CI⫽5.3, 10.6)
0
and for hypothermia (i.e.,
No Ban 1
Ban 1
No Ban 2
Ban 2
(Nov 93–Oct 94)
(Nov 94–Oct 95) (Nov 95–Feb 96)
(Mar 96–Jul 96)
freezing to death; RR⫽30.5;
95% CI⫽17.7, 48.7). FurtherBan periods
more, American Indians in
New Mexico who died of
Figure 2. Alcohol-related outpatient visits associated with changes in alcohol ban policy,
these causes were likely to
Barrow, Alaska, 1993–199650
December 2009
Am J Prev Med 2009;37(6)
563
have elevated blood alcohol levels (an average of 0.24
g/dL and 0.18 g/dL for pedestrian deaths and
hypothermia, respectively). A disproportionate number (67%) of these deaths occurred in counties
bordering reservations, despite the fact that most
American Indians live on reservations. Although the
design of this study does not allow causal inference
regarding the effect of bans, these findings suggest that
travel between dry reservations and adjacent areas where
alcohol is readily available may increase the risk of death
from these external causes among those traveling offreservation to purchase alcohol.
Summary
The effectiveness of bans in reducing alcohol-related
harms appears to be highly dependent on the availability of alcohol in the surrounding area. In isolated
communities, bans can substantially reduce alcoholrelated harms. However, where alcohol is available in
areas nearby those with bans, travel between these areas
may lead to serious harms.
Studies of Licensing-Policy Changes Affecting
Outlet Density
The team identified four studies of national or local
licensing-policy changes that resulted in increased outlet density. The studies were conducted in Iceland,60
Finland,47 New Zealand,61 and North Carolina.62 The
policy changes assessed occurred between 1969 and
1990. The North Carolina study was of greatest design
suitability and good execution. The other three studies
were of moderate design suitability and good execution.47,60,61 These studies examined various indices of
alcohol consumption; the North Carolina study also assessed effects on alcohol-related motor-vehicle crashes.
Another study assessed the effect of a change in national
policy controlling the sale of table wine in New Zealand.
Effects on Excessive Alcohol Consumption and
Related Harms
The only U.S. study that met criteria for this category of
interventions evaluated the decision by several North
Carolina counties to allow on-premises sale of spirits
(i.e., “liquor by the drink” [LBD]), replacing the previous option of “brown-bagging,”62 in which patrons of
an establishment bring their own alcoholic beverage
(in a bag) and the establishment supplies other items
(e.g., a drink glass, ice, water). Of the 100 counties in
North Carolina, three approved liquor by the drink in
November 1978 and eight approved it in January 1979.
The policy change was followed by the opening of many
bars and lounges adjacent to restaurants. Interrupted
time–series models indicated that, relative to counties
that did not change their policies, sales of spirits
increased in LBD counties by 8.2% (p⬍0.05) among
564
the first group of counties to adopt the new policy, and
by 4.3% (p⬍0.05) among the second group. Nighttime
single-vehicle crashes among men of legal drinking age
also increased in both early- and late-adopting counties
by 18.5% (p⬍0.01) and 15.7% (p⬍0.01), respectively.
However, there were no significant changes in rates of
nighttime single-vehicle crashes among boys/men aged
⬍21 years, who were not permitted to drink spirits and
were thus not (legally) affected by the policy change.
In Finland, the enactment in 1969 of a policy allowing the sale of medium-strength beer resulted in a 22%
increase in the number of monopoly alcohol outlets
and a 46% increase in restaurant liquor licenses, and
permitted 17,400 grocery stores to sell mediumstrength beer. During the year following these changes,
overall alcohol sales in Finland increased by 46%. Of
the increase, 86% was attributed by the researchers to
the increased availability of beer. Overall alcohol consumption increased by 56%, with the greatest volume
increases among those drinking more than a half liter
of pure alcohol per year (1/2 liter of pure alcohol is
equivalent to 1/3 gallon of 80-proof liquor). However,
alcohol consumption increased significantly among all
adults at all levels of alcohol consumption in Finland
subsequent to this policy change, regardless of their
baseline pattern of consumption, including those who
had previously reported that they had not consumed
alcohol during the past year.
In Iceland,60 a policy change in 1989 resulted in an
expansion in off-premises monopoly outlets and commercial
on-premises outlets in Reykjavik and in rural areas. Over the
subsequent 4-year period, consumption increased by 43%
among men who drank more than 350 centiliters of alcohol
per year at baseline, but changed minimally among women
and men who drank at lower levels.
In New Zealand,61 a policy change in 1989 allowed
the sale of table wine in grocery stores, resulting in an
increase of approximately 25% in the number of wine
outlets in the country over a 2-year period. This resulted in a 17% (95% CI⫽9.8%, 24.9%) increase in
wine sales during this time, but in no change in the
sales of other alcoholic beverages. This indicates that
there was an overall increase in alcohol consumption in
New Zealand subsequent to this policy change, and that
wine, the privatized beverage, was not being substituted
for other nonprivatized alcoholic beverages.
Summary
These studies consistently indicated that more permissive licensing procedures increased the number of onand off-premises alcohol outlets, which in turn led to
increases in alcohol consumption. Two of these studies
specifically reported increases in alcohol consumption
among heavy drinkers, and one study reported an
increase in drinking among survey subjects who reported not drinking during a specified period at the
American Journal of Preventive Medicine, Volume 37, Number 6
www.ajpm-online.net
baseline assessment. The single study that evaluated
alcohol-related harms (alcohol-related motor-vehicle
crashes) found that they increased substantially after
allowing the sale of liquor by the drink.
Intervention Effectiveness—Secondary Evidence
Although the primary evidence just reviewed is heterogeneous in topic and design and does not allow
summary tabular presentation, the secondary evidence presented below is based on consistent statistical procedures and readily allows a summary table.
Cross-Sectional Studies
Findings from studies of on- and off-premises outlets
combined. The 28 cross-sectional studies19,55–57,63– 86
that assessed the association of outlet density (onpremise and off-premise, not distinguished) assessed
47 alcohol-related outcomes. Of these outcomes, 41
(87.2%) found a positive association, that is, as density
increased, so did consumption and alcohol-related
harms, and vice versa (Table 1, A). Positive associations
were found for consumption-related outcomes (e.g.,
per capita alcohol consumption); violence and injury
outcomes; and several medical conditions (e.g., liver
disease). The mean elasticities ranged from 0.045 for
crime to 0.421 for motor-vehicle crashes.
Findings from studies of on-premises outlets. The 23
studies23,58,78,79,87–105 that assessed the association of
outlet density and alcohol-related outcomes in onpremises outlets reported on 25 outcomes. Of these, 21
(84.0%) indicated a positive association (Table 1, B).
Positive associations were also found for consumptionrelated outcomes, several forms of violence and injury
outcomes related to alcohol consumption, and one medical condition. Mean study elasticities could be estimated
for most outcome types, and values ranged from 0.021 for
child abuse to 0.250 for population consumption.
Findings from studies of off-premises outlets. The 23
studies58,79,89 –92,94 –99,101–111 that assessed the association of outlet density and alcohol-related outcomes in
off-premises outlets reported on 24 outcomes. Of these,
18 (75.0%) also indicated a positive association (Table
1, C). Positive associations were found for consumption-related outcomes, several forms of violence and
injury outcomes related to alcohol consumption, and
one medical condition. Mean study elasticities could be
estimated for most outcome types and values ranged
from ⫺0.15 for injury to 2.46 for population consumption. Mean elasticity was also high (0.483) for violent
crime.
Summary
Cross-sectional studies generally show consistent positive associations between alcohol outlet density and
December 2009
Table 1. Cross-sectional studies, outcomes by setting type
# of
studies
Outcomes
A. ON- AND OFF-PREMISES
Consumption
Population consumption
Binge drinking
Underage drinking
Violence and injury
Violent crime
Injury
Motor-vehicle crashes
Drunk driving
Crime
Medical conditions
Alcohol medical visits
Alcoholism
Liver disease
Total all premises
B. ON-PREMISES
Consumption
Population consumption
Binge drinking
Violence and injury
Violent crime
Injury
Motor-vehicle crashes
Drunk driving
Crime
Child abuse
Medical conditions
Liver disease
Total on-premises
C. OFF-PREMISES
Consumption
Population consumption
Binge drinking
Violence and injury
Violent crime
Injury
Motor-vehicle crashes
Drunk driving
Crime
Child abuse
Medical conditions
Liver disease
Total off-premises
%
positive
M
elasticity
AGGREGATED
7
5
2
85.7
80.0
100.0
0.27
15
3
6
1
2
93.3
100.0
50.0
100.0
100.0
0.32
0.23
0.42
1
1
4
47
100.0
100.0
100.0
87.2
3
1
33.3
100.0
0.25
4
3
6
2
1
2
100.0
100.0
66.7
100.0
100.0
100.0
0.12
0.14
0.05
3
25
100.0
84.0
0.06
2
1
100.0
100.0
2.46
6
3
5
2
1
2
100.0
66.7
80.0
50.0
100.0
100.0
0.48
⫺0.15
0.10
2
24
50.0
76.9
⫺0.05
0.04
0.02
0.01
excessive alcohol consumption and related harms, with
the possible exception of injuries, for which the findings were less consistent. The largest effect sizes were
for studies relating outlet density to population consumption and violent crime.
Summary of the Body of Scientific Evidence on
Alcohol Outlet Density and Excessive Drinking
and Related Harms
Using a variety of different study methods, study populations, and alcohol measures, most of the studies
included in this review reported that greater outlet
Am J Prev Med 2009;37(6)
565
density is associated with increased alcohol consumption and related harms, including medical harms, injuries, crime, and violence. This convergent evidence
comes both from studies that directly evaluated outlet
density (or changes in outlet density) and those that
evaluated the effects of policy changes that had a
substantial impact on outlet density, including studies
of privatization, remonopolization, bans on alcohol
sales and the removal of bans, and changes in density
from known policy interventions and from unknown
causes. Studies assessing the relationship between alcohol outlet density and motor-vehicle crashes produced
mixed results.18,20,62,112
Other Benefits and Harms
Communities commonly seek limits on alcohol outlet
density, either through licensing or zoning, for purposes that may not be directly related to public health
(e.g., the reduction of public nuisance, loitering, vandalism, and prostitution).7,113 Although the team did
not specifically search for studies that assessed these
outcomes, some of the studies the team reviewed
suggested that there may be an association between
outlet density and these outcomes as well. For example,
a study from New South Wales, Australia, reported an
association between outlet density and “neighborhood
problems with drunkenness” but did not find a significant association with property damage.114 There was
evidence of one potential harm of decreased outlet
density (i.e., an increase in fatal single-vehicle nighttime vehicle crashes) presumably associated with an
increase in driving in response to greater distances
between alcohol outlets.19
Applicability
Evidence of the association of outlet density and alcohol consumption and related harms derives from studies conducted primarily in North American and in
Scandinavian countries. One study27 indicated that the
impact of changes in outlet density may be affected by
demographic characteristics (e.g., gender distribution)
of the population; in this case, the association of outlet
density with assaults requiring hospitalization was stronger where there was a greater proportion of boys/men
in the population. Most of the studies reviewed assessed
the effects of increased outlet density, which is a
consequence of the general trend toward liberalization
of alcohol policies associated with outlet density. Few
data were found from which to draw inferences about
regulations that control or reduce outlet density.
Studies of bans on alcohol sales, conducted primarily
among American Indian and Alaska Native populations, consistently report a reduction in excessive consumption and related harms following the implementation of a ban on alcohol sales, possession, or both,
566
provided the area affected by the ban was not surrounded by other sources of alcoholic beverages.
Barriers
Reductions in outlet density, with resultant reductions
in consumption, are likely to have substantial commercial and fiscal consequences, and thus may be opposed
by commercial interests in the manufacture, distribution, and sale of alcoholic beverages. In keeping with its
commercial interests, the alcoholic beverage industry
has tended to support policies that facilitate outlet
expansion.115
State pre-emption laws (i.e., laws that prevent implementation and enforcement of local restrictions) can
also undermine efforts by local governments to regulate alcohol outlet density.7 Indeed, the elimination of
pre-emption laws related to the sale of tobacco products is one of the health promotion objectives in Healthy
People 2010.13 However, there is no similar objective in
Healthy People 2010 related to the sale of alcoholic
beverages.
Economic Evaluation
The team’s systematic economic review did not identify
any study that examined the costs and benefits of
limiting alcohol outlet density. Although there has
been speculation that reducing the number of alcohol
outlets may result in a loss of revenue to state and local
governments owing to a loss of licensing fees and
alcohol tax revenues, the team found no studies that
have documented this speculation. In addition, there
may be economic gains resulting from revenue generation from merchants and consumers who would otherwise avoid areas known to have a high alcohol outlet
density; however, the team found no studies about this
topic. Moreover, in 2006, alcoholic beverage licenses
accounted for only $406 million (0.9%) of the $45 billion
that state governments received from all licensing fees,
and alcohol taxes accounted for only 0.7% of all taxes
($4.9 billion of $706 billion) collected by state govern
ments (www.census.gov//govs/statetax/0600usstax.
html).
Even in the absence of published data on program
implementation costs and other costs related to this
intervention, it should be expected that the cost of
restricting access to alcohol by limiting the number of
alcohol outlets is likely to be small relative to the
societal cost of excessive alcohol consumption in the
U.S. For example, in 1998, the most recent year for
which data are available, the societal cost of excessive
alcohol consumption in the U.S. was $185 billion,
including, among other costs, approximately $87 billion in lost productivity due to morbidity, $36 billion in
lost future earnings due to premature deaths, $19
billion in medical care costs, $10 billion in lost earnings
due to crime, $6 billion in costs to the criminal justice
American Journal of Preventive Medicine, Volume 37, Number 6
www.ajpm-online.net
system, and $16 billion in property damage related to
motor-vehicle crashes.4 Moreover, each state alcohol
enforcement agent is responsible for monitoring an
average of 268 licensed establishments116; thus, reducing the number of retail alcohol outlets might reduce
their enforcement responsibilities. In summary, no
existing study examines the economic costs and benefits of limiting alcohol outlet density.
Research Gaps
Although the scientific evidence reviewed indicates that
the regulation of alcohol outlet density can be an
effective means of controlling excessive alcohol consumption and related harms, it would be useful to
conduct additional research to further assess this relationship:
●
●
●
●
●
There are few if any studies evaluating how local
decisions are made regarding policies affecting alcoholic beverage outlet density or the consequences of
such policy changes. Such case studies may be difficult to conduct, but they could provide important
insights to guide policy decisions regarding alcohol
outlet density in other communities.
The majority of outlet density research explores the
impact of increasing alcohol outlet density on alcoholrelated outcomes; there is a lack of research on the
impact of reducing outlet density. This might be
done by observing the impact of temporal changes
in outlet density on excessive alcohol consumption
and related harms.
The association of on- and off-premises alcoholic
beverage outlets with illegal activities such as prostitution and drug abuse should be examined. In
themselves, these may have adverse public health
and other outcomes; in addition, they may confound
the apparent association of alcohol outlets with
these outcomes.
Relatively little is known about the impact of density
changes relative to baseline density levels. Some
authors (e.g., Mann117) have proposed that the
association between outlet density and alcohol consumption follows a demand curve, such that when
density is relatively low, increases in density may be
expected to have large effects on consumption, and
when density is relatively high, increases in density
should be expected to have smaller effects.21,117
Thus, it would be useful to assess this hypothesis
empirically using econometric methods, with different kinds of alcohol-related outcomes. Such information would allow communities at different alcohol outlet density “levels” to project the possible
benefits of reducing density by specific amounts or
the potential harms of increasing density.
For public health practitioners, legislators, and others attempting to control alcohol outlet density to
reduce alcohol-related harms, it would be useful to
December 2009
●
catalog approaches to regulation beyond licensing
and zoning that may have an effect on outlet density
(e.g., traffic or parking regulations that, in effect,
control the number of driving patrons who may
patronize an alcohol outlet).
A primary rationale for limiting alcohol outlet density is to improve public health and safety. Furthermore, the economic efficiency of limiting outlet
density is difficult to assess without data on the
economic impact of this intervention. To remedy
this, future studies on the impact of changes in
alcohol outlet density should assess both health and
economic outcomes, so that the economic impact of
this intervention can be assessed empirically.
The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position
of the CDC.
The authors are grateful for the contributions of Ralph
Hingson, ScD, MPH (National Institute of Alcohol Abuse and
Alcoholism), and Steve Wing (Substance Abuse and Mental
Health Services).
No financial disclosures were reported by the authors of
this paper.
References
1. CDC. Alcohol-attributable deaths and years of potential life lost—United
States, 2001. MMWR Morb Mortal Wkly Rep 2004;53(37):866 –70.
2. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated
health risk behaviors among high school students. Pediatrics 2007;
119(1):76 – 85.
3. National Center for Health Statistics. Health, United States, 2005 with
chartbook on trends in the health of America. Hyattsville MD: National
Center for Health Statistics, 2005. USDHHS No. 2005–1232.
4. Harwood H. Updating estimates of the economic costs of alcohol abuse in
the United States: estimates, update methods, and data. Rockville MD:
National Institute on alcohol Abuse and Alcoholism, 2000. NIH Publication No. 98-4327.
5. National Alcoholic Beverage Control Association. NABCA survey book.
Alexandria VA: NABCA, 2005.
6. Ashe M, Jernigan D, Kline R, Galaz R. Land use planning and the control
of alcohol, tobacco, firearms, and fast food restaurants. Am J Public
Health 2003;93(9):1404 – 8.
7. Mosher J. Alcohol issues policy briefing paper: the perils of preemption.
Chicago IL: American Medical Association, 2001.
8. Babor TF, Caetano R, Casswell S, et al. Alcohol: no ordinary commodity—
research and public policy. Oxford: Oxford University Press, 2003.
9. Grover PL, Bozzo R. Preventing problems related to alcohol availability:
environmental approaches. Rockville MD: SAMHSA/CSAP, 1999. DHHS
Publication No. (SMA) 99-3298.
10. WHO. European Alcohol Action Plan, 2000 –2005. Copenhagen: WHO,
2000.
11. WHO. Draft regional strategy to reduce alcohol-related harm. Auckland,
New Zealand: WHO, 2006.
12. Livingston M, Chikritzhs T, Room R. Changing the density of alcohol outlets
to reduce alcohol-related problems. Drug Alcohol Rev 2007;26:557– 66.
13. USDHHS. Healthy People 2010. Washington DC: USDHHS, 2001.
14. Task Force on Community Preventive Services. The Guide to Community Preventive Services. What works to promote health? In: Zaza S,
Briss PA, Harris KW, eds. New York: Oxford University Press, 2005.
www.thecommunityguide.org.
15. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based
Guide to Community Preventive Services—methods. Am J Prev Med
2000;18(1):35– 43.
Am J Prev Med 2009;37(6)
567
16. Zaza S, Wright-De Aguero LK, Briss PA, et al. Data collection instrument
and procedure for systematic reviews in the Guide to Community Preventive Services. Am J Prev Med 2000;18(1):44 –74.
17. Lipsey MW, Wilson DB, Cohen MA, Derzon JH. Is there a causal
relationship between alcohol use and violence? In: Galanter M, ed. Recent
developments in alcoholism. Vol. XIII. Alcohol and violence. New York:
Plenum Press, 1997:245– 82.
18. Baughman R, Conlin M, Dickert-Conlin S, Pepper J. Slippery when wet:
the effects of local alcohol access laws on highway safety. J Health Econ
2001;20(6):1089 –96.
19. Gruenewald PJ, Treno AJ, Nephew TM, Ponicki WR. Routine activities and
alcohol use: constraints on outlet utilization. Alcohol Clin Exp Res
1995;19(1):44 –53.
20. McCarthy P. Alcohol-related crashes and alcohol availability in grass-roots
communities. Appl Econ 2003;35(11):1331– 8.
21. Her M, Giesbrecht N, Room R, Rehm J. Privatizing alcohol sales and
alcohol consumption: evidence and implications. Addiction 1999;94(8):
1125–39.
22. World Bank. World Development Indicators 2006. devdata.worldbank.
org/wdi2006/contents/cover.htm.
23. Gruenewald PJ, Millar AB, Treno AJ, Yang Z, Ponicki WR, Roeper P. The
geography of availability and driving after drinking. Addiction 1996;
91(7):967– 83.
24. Cook PJ, Skog OJ. Alcool, alcoolisme, alcoolisation: comment. Alcohol
Health Res World 1995;19(1):30 –1.
25. Blake D, Nied A. The demand for alcohol in the United Kingdom. Appl
Econ 1997;29:1655–72.
26. Gruenewald PJ, Ponicki WR, Holder HD. The relationship of outlet
densities to alcohol consumption: a time series cross-sectional analysis.
Alcohol Clin Exp Res 1993;17(1):38 – 47.
27. Gruenewald PJ, Remer L. Changes in outlet densities affect violence rates.
Alcohol Clin Exp Res 2006;30(7):1184 –93.
28. Hoadley JF, Fuchs BC, Holder HD. The effect of alcohol beverage
restrictions on consumption: a 25-year longitudinal analysis. Am J Drug
Alcohol Abuse 1984;10(3):375– 401.
29. Markowitz S, Chatterji P, Kaestner R. Estimating the impact of alcohol
policies on youth suicides. J Ment Health Policy Econ 2003;6(1):37– 46.
30. McCarthy P. Alcohol, public policy, and highway crashes: a time-series
analysis of older-driver safety. Transp Econ Policy 2005;39(1):109 –25.
31. McCornac DC, Filante RW. The demand for distilled spirits: an empirical
investigation. J Stud Alcohol 1984;45(2):176 – 8.
32. Norstrom T. Outlet density and criminal violence in Norway, 1960 –1995.
J Stud Alcohol 2000;61(6):907–11.
33. Xie X, Mann RE, Smart RG. The direct and indirect relationships between
alcohol prevention measures and alcoholic liver cirrhosis mortality. J Stud
Alcohol 2000;61(4):499 –506.
34. Fitzgerald JL, Mulford HA. Consequences of increasing alcohol availability: the Iowa experience revisited. Br J Addict 1992;87(2):267–74.
35. Holder HD, Wagenaar AC. Effects of the elimination of a state monopoly
on distilled spirits’ retail sales: a time-series analysis of Iowa. Br J Addict
1990;85:1615–25.
36. Trolldal B. The privatization of wine sales in Quebec in 1978 and 1983 to
1984. Alcohol Clin Exp Res 2005;29(3):410 – 6.
37. MacDonald S. The impact of increased availability of wine in grocery
stores on consumption: four case histories. Br J Addict 1986;81:381–7.
38. Mulford HA, Fitzgerald JL. Consequences of increasing off-premise wine
outlets in Iowa. Br J Addict 1988;83(11):1271–9.
39. Mulford HA, Ledolter J, Fitzgerald JL. Alcohol availability and consumption: Iowa sales data revisited. J Stud Alcohol 1992;53(5):487–94.
40. Ramstedt M. The repeal of medium-strength beer in grocery stores in
Sweden—the impact on alcohol-related hospitalizations in different age
groups. Finland: Nordic Council for Alcohol and Drug Research (NAD),
2002. No. 42.
41. Smart RG, Docherty D. Effects of the introduction of on premise drinking
on alcohol-related accidents and impaired driving. J Stud Alcohol
1976;37:683– 6.
42. Trolldal B. An investigation of the effect of privatization of retail sales of
alcohol on consumption and traffic accidents in Alberta, Canada. Addiction 2005;100(5):662–71.
43. Wagenaar AC, Holder HD. A change from public to private sale of wine:
results from natural experiments in Iowa and West Virginia. J Stud
Alcohol 1991;52(2):162–73.
44. Wagenaar AC, Holder HD. Changes in alcohol consumption resulting
from the elimination of retail wine monopolies: results from five U.S.
states. J Stud Alcohol 1995;56(5):566 –72.
568
45. Fitzgerald JL, Mulford HA. Privatization, price and cross-border liquor
purchases. J Stud Alcohol 1993;54(4):462– 4.
46. Smart RG. The impact on consumption of selling wine in grocery stores.
Alcohol Alcohol 1986;21(3):233– 6.
47. Makela P. Whose drinking does the liberalization of alcohol policy
increase? Change in alcohol consumption by the initial level in the
Finnish panel survey in 1968 and 1969. Addiction 2002;97(6):701– 6.
48. Berman MHT. Alcohol control by referendum in Northern native communities: the Alaska local option law. Arctic 2001;54(1):77– 83.
49. Bowerman RJ. The effect of a community supported alcohol ban on
prenatal alcohol and other substance abuse. Am J Public Health
1997;87(8):1378 –9.
50. Chiu AY, Perez PE, Parker RN. Impact of banning alcohol on outpatient
visits in Barrow, Alaska. JAMA 1997;278(21):1775–7.
51. May P. Arrests, alcohol and alcohol legalization among an American
Indian tribe. Plains Anthropol 1975;20(68):129 –34.
52. O’Neil JD. Community control over health problems: alcohol prohibition
in a Canadian Inuit village. Int J Circumpolar Health 1984;84:340 –3.
53. Berman M, Hull T, May P. Alcohol control and injury death in Alaska
native communities: wet, damp and dry under Alaska’s local option law. J
Stud Alcohol 2000;61(2):311–9.
54. Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and
hypothermia deaths among Native Americans in New Mexico: between
bar and home. JAMA 1992;267(10):1345– 8.
55. Britt H, Carlin BP, Toomey TL, Wagenaar AC. Neighborhood-level spatial
analysis of the relationship between alcohol outlet density and criminal
violence. Environ Ecol Stat 2005;12:411–26.
56. Escobedo LG, Ortiz M. The relationship between liquor outlet density and
injury and violence in New Mexico. Accid Anal Prev 2002;34(5):689 –94.
57. Parker DA, Wolz MW, Harford TC. The prevention of alcoholism: an
empirical report on the effects of outlet availability. Alcohol Clin Exp Res
1978;2(4):339 – 43.
58. Treno AJ, Gruenewald PJ, Johnson FW. Alcohol availability and injury: the
role of local outlet densities. Alcohol Clin Exp Res 2001;25(10):1467–71.
59. Wood DS, Gruenewald PJ. Local alcohol prohibition, police presence
and serious injury in isolated Alaska Native villages. Addiction
2006;101(3):393– 403.
60. Olafsdottir H. The dynamics of shifts in alcoholic beverage preference:
effects of the legalization of beer in Iceland. J Stud Alcohol 1998;
59(1):107–14.
61. Wagenaar AC, Langley JD. Alcohol licensing system changes and alcohol
consumption: introduction of wine into New Zealand grocery stores.
Addiction 1995;90(6):773– 83.
62. Blose JO, Holder HD. Public availability of distilled spirits: structural and
reported consumption changes associated with liquor-by-the-drink. J Stud
Alcohol 1987;48(4):371–9.
63. Dull RT. An assessment of the effects of alcohol ordinances on selected
behaviors and conditions. J Drug Issues 1986;16(4):511–21.
64. Dull RT. Dry, damp, and wet: correlates and presumed consequences of
local alcohol ordinances. Am Drug Alcohol Abuse 1988;14(4):499 –514.
65. Gorman DM, Speer PW, Labouvie EW, Subaiya AP. Risk of assaultive
violence and alcohol availability in New Jersey. Am J Public Health
1998;88(1):97–100.
66. Gorman DM, Labouvie EW, Speer PW, Subaiya AP. Alcohol availability
and domestic violence. Am J Drug Alcohol Abuse 1998;24(4):661–73.
67. Gorman D, Speer P, Gruenewald P, Labouvie E. Spatial dynamics of
alcohol availability, neighborhood structure and violent crime. J Stud
Alcohol 2001;62(5):628 –36.
68. Gyimah-Brempong K. Alcohol availability and crime: evidence from
census tract data. South Econ J 2001;68(1):2–21.
69. Jewell R, Brown R. Alcohol availability and alcohol-related motor vehicle
accidents. Appl Econ 1995;27:759 – 65.
70. Markowitz S, Grossman M. Alcohol regulation and domestic violence
towards children. Contemp Econ Policy 1998;16(3):309 –20.
71. Neuman C, Rabow J. Drinkers’ use of physical availability of alcohol: buying
habits and consumption level. Inter Addict 1985;20(11–12):1663–73.
72. Nielsen AL, Martinez R, Lee MT. Alcohol, ethnicity, and violence: the role
of alcohol availability for Latino and Black aggravated assaults and
robberies. Sociol Q 2005;46:479 –502.
73. Ornstein S, Hanssens D. Alcohol control laws and the consumption of
distilled spirits and beer. J Consum Res 1985;12(2):200 –13.
74. Parker DA. Alcohol problems and the availability of alcohol. Alcohol Clin
Exp Res 1979;3(4):309 –12.
American Journal of Preventive Medicine, Volume 37, Number 6
www.ajpm-online.net
75. Pollack CE, Cubbin C, Ahn D, Winkleby M. Neighbourhood deprivation
and alcohol consumption: does the availability of alcohol play a role? Int
J Epidemiol 2005;34(4):772– 80.
76. Reid RJ, Hughey J, Peterson NA. Generalizing the alcohol outlet-assaultive
violence link: evidence from a U.S. Midwestern city. Subst Use Misuse
2003;38(14):1971– 82.
77. Rush BR, Gliksman L, Brook R. Alcohol availability, alcohol consumption
and alcohol-related damage. I. The distribution of consumption model. J
Stud Alcohol 1986;47(1):1–10.
78. Scribner RA. The risk of assaultive violence and alcohol availability. Am J
Public Health 1995;85(3):335– 40.
79. Scribner RA, MacKinnon DP, Dwyer JH. Alcohol outlet density and
motor vehicle crashes in Los Angeles County cities. J Stud Alcohol
1994;55(4):447–53.
80. Smart RG. Effects of two liquor store strikes on drunkenness, impaired
driving and traffic accidents. J Stud Alcohol 1977;38(9):1785–9.
81. Speer PW, Gorman DM, Labouvie EW, Ontkush MJ. Violent crime and
alcohol availability: relationships in an urban community. J Public Health
Policy 1998;19(3):303–18.
82. Stevenson RJ, Lind B, Weatherburn D. The relationship between
alcohol sales and assault in New South Wales, Australia. Addiction
1999;94(3):397– 410.
83. Tatlow JR, Clapp JD, Hohman MM. The relationship between the
geographic density of alcohol outlets and alcohol-related hospital admissions in San Diego County. J Community Health 2000;25(1):79 – 88.
84. Treno A, Grube J, Martin S. Alcohol availability as a predictor of youth
drinking and driving: a hierarchical analysis of survey and archival data.
Alcohol Clin Exp Res 2003;27(5):835– 40.
85. Weitzman ER, Folkman A, Folkman MP, Wechsler H. The relationship of
alcohol outlet density to heavy and frequent drinking and drinkingrelated problems among college students at eight universities. Health
Place 2003;9(1):1– 6.
86. Zhu L, Gorman DM, Horel S. Alcohol outlet density and violence: a
geospatial analysis. Alcohol Alcohol 2004;39(4):369 –75.
87. Colon I. Alcohol availability and cirrhosis mortality rates by gender and
race. Am J Public Health 1981;71(12):1325– 8.
88. Colon I, Cutter HS. The relationship of beer consumption and state
alcohol and motor vehicle policies to fatal accidents. J Safety Res
1983;14(2):83–9.
89. Freisthler B, Gruenewald PJ, Treno AJ, Lee J. Evaluating alcohol access
and the alcohol environment in neighborhood areas. Alcohol Clin Exp
Res 2003;27(3):477– 84.
90. Freisthler B. A spatial analysis of social disorganization, alcohol access,
and rates of child maltreatment in neighborhoods. Child Youth Serv Rev
2004;26(9):803–19.
91. Freisthler B, Needell B, Gruenewald PJ. Is the physical availability of
alcohol and illicit drugs related to neighborhood rates of child maltreatment? Child Abuse Negl 2005;29(9):1049 – 60.
92. Godfrey C. Licensing and the demand for alcohol. Appl Econ
1988;20:1541–58.
93. Harford T, Parker D, Pautler C, Wolz M. Relationship between the number
of on-premise outlets and alcoholism. Stud Alcohol 1979;40(11):1053–7.
94. Gruenewald PJ, Johnson FW, Treno AJ. Outlets, drinking and driving: a
multilevel analysis of availability. J Stud Alcohol 2002;63(4):460 – 8.
95. Kelleher KJ, Pope SK, Kirby RS, Rickert VI. Alcohol availability and motor
vehicle fatalities. J Adolesc Health 1996;19(5):325–30.
96. Lascala EA, Gerber D, Gruenewald PJ. Demographic and environmental
correlates of pedestrian injury collisions: a spatial analysis. Accid Anal Prev
2000;32:651– 8.
December 2009
97. LaScala EA, Johnson FW, Gruenewald PJ. Neighborhood characteristics of
alcohol-related pedestrian injury collisions: a geostatistical analysis. Prev
Sci 2001;2(2):123–34.
98. Lipton R, Gruenewald P. The spatial dynamics of violence and alcohol
outlets. J Stud Alcohol 2002;63(2):187–95.
99. Rabow J, Watts RK. Alcohol availability, alcoholic beverage sales and
alcohol-related problems. J Stud Alcohol 1982;43(7):767– 801.
100. Roncek DW, Maier PA. Bars, blocks, and crimes revisited: linking the
theory of routine activities to the empiricism of “hot spots.” Criminology
1991;29(4):725–53.
101. Scribner R, Cohen D, Kaplan S, Allen SH. Alcohol availability and
homicide in New Orleans: conceptual considerations for small area
analysis of the effect of alcohol outlet density. J Stud Alcohol
1999;60(3):310 – 6.
102. Stout EM, Sloan FA, Liang L, Davies HH. Reducing harmful alcohol-related
behaviors: effective regulatory methods. J Stud Alcohol 2000;61(3):402–12.
103. Watts RK. Alcohol availability and alcohol-related problems in 213 California cities. Alcohol Clin Exp Res 1983;7(1):47–58.
104. Wieczorek WF, Coyle JJ. Targeting DWI prevention. J Prev Interv Community 1998;17(1):15–30.
105. van Oers JA, Garretsen HF. The geographic relationship between alcohol
use, bars, liquor shops and traffic injuries in Rotterdam. J Stud Alcohol
1993;54(6):739 – 44.
106. Alaniz ML. Immigrants and violence: the importance of neighborhood
context. Hisp J Behav Sci 1998;20(2):155–74.
107. Cohen DA, Mason K, Scribner R. The population consumption model,
alcohol control practices, and alcohol-related traffic fatalities. Prev Med
2002;34(2):187–97.
108. Colon I. The influence of state monopoly of alcohol distribution and the
frequency of package stores on single motor vehicle fatalities. Am J Drug
Alcohol Abuse 1982;9(3):325–31.
109. Freisthler B, Midanik LT, Gruenewald PJ. Alcohol outlets and child
physical abuse and neglect: applying routine activities theory to the study
of child maltreatment. J Stud Alcohol 2004;65(5):586 –92.
110. Gorman DM, Zhu L, Horel S. Drug ‘hot-spots,’ alcohol availability and
violence 220. Drug Alcohol Rev 2005;24(6):507–13.
111. Scribner RA, Cohen DA, Fisher W. Evidence of a structural effect for
alcohol outlet density: a multilevel analysis. Alcohol Clin Exp Res
2000;24(2):188 –95.
112. McCarthy PS. Public policy and highway safety: a city-wide perspective.
Reg Sci Urban Econ 1999;29(2):231– 44.
113. Wittman FD, Hilton ME. Uses of planning and zoning ordinances to
regulate alcohol outlets in California cities. In: Holder HD, ed. Control
issues in alcohol abuse prevention: strategies for states and communities.
Greenwich CT: JAI Press, 1987:337– 66.
114. Donnelly N, Poynton S, Weatherburn D, Bamford E, Nottage J. Liquor
outlet concentrations and alcohol-related neighborhood problems. Alcohol Stud Bull 2006;8:1–16.
115. Giesbrecht N. Roles of commercial interests in alcohol policies: recent
developments in North America. Addiction 2000;95(4):S581–95.
116. National Highway Traffic Safety Administration. The role of alcohol
beverage control agencies in the enforcement and adjudication of alcohol
laws. No. DOT HS 809 877.
117. Mann R, Rehm J, Giesbrecht N, et al. The effect of different forms of alcohol
distribution and retailing on alcohol consumption and problems—an analysis of available research. Toronto: Center for Addiction and Mental Health,
2005.
Am J Prev Med 2009;37(6)
569